Thurs., 10/13/11 Polytrauma, Paper #27, 3:02 pm OTA-2011
Delayed Wound Closure Increases Deep Infection Rate in Lower Grade Open Fractures: A Propensity-Matched Cohort Study
Richard J. Jenkinson, MD, FRCS(C); Alexander Kiss, PhD; Samuel C. Johnson, MD;
David J.G. Stephen, MD, FRCS(C); Hans J. Kreder, MD, MPH, FRCS(C);
University of Toronto, Toronto, Ontario, Canada
Purpose: Traumatic wounds after open fractures have traditionally been left open in hopes of minimizing rates of infection. Our study aims to compare the rate of subsequent deep infection among open fracture patients treated with either immediate primary closure after débridement or delayed primary closure while minimizing bias using a matched-pairs design.
Methods: A review of open fractures of the 4 years from 2003 to 2006, inclusive, at our Level 1 trauma center identified 360 fractures with Gustilo-Anderson grading of 1, 2, or 3A. 92 fractures were treated with delayed primary closure while 268 were treated with immediate closure after surgical débridement. A deep infection was defined as the need for an unplanned return to the operating room for an additional irrigation and débridement or treatment of an infected nonunion. To provide similar groups, a propensity score was created using a logistic regression equation predicting the likelihood of treatment with delayed primary closure. The propensity score algorithm incorporated terms for age, sex, time to débridement, ASA (American Society of Anesthesiologists) score, ISS, gunshot versus blunt mechanism, fracture grade, presence of gross contamination, and tibial versus other anatomic site. A one-to-one matching algorithm based on this propensity score was used to generate 75 matched pairs of fractures in individual patients.
Results: Among the original groupings, the 92 fractures treated with delayed primary closure had a higher infection rate (17% vs 3%; P = 0.0009); however, these fractures tended to be more severe injuries with a higher proportion of grade 3 fractures (P = 0.0003), tibia fractures (P = 0.018), and gross contamination (P = 0.0001). After applying the propensity-matching algorithm, the 2 treatment groups showed similar characteristics among all of the elements of the propensity score including fracture grade (P = 1.0), gross contamination (P = 0.86), and tibial fractures (P = 0.87). Deep infection developed among 4 of the 75 open fractures treated with immediate closure (5.3%) compared to 15 of the 75 fractures treated with delayed primary closure (20%). This was statistically significant with standard statistics (Fisher exact test P = 0.0124) and when accounting for the paired data using conditional logistic regression (odds ratio = 3.75; 95% confidence interval, 1.245-11.29).
Conclusion: Immediate closure of wounds in grade 1, 2, and 3A open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.